10/8/2015
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Debra J. Drew, MS, ACNS-BC, RN-BC, AP-PMN
Implementation of the
CAPA©(Clinically Aligned Pain
Assessment) Tool:
Pain is More than Just a Number©
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Conflict of Interest Disclosure
• Author’s Conflict of
Interest
No Conflicts of Interest
Objectives
Learners will be able to:
1. Discuss the concept of pain assessment as a
social transaction between patient and
clinician.
2. Summarize the outcomes of University of
Minnesota Health’s implementation of
CAPA©.
3. Describe the lessons learned from
implementing a complex and culture-changing
project.
Impetus for Change at University of
Minnesota Medical Center2012
• Low patient pain satisfaction scores (HCAPH)
• Anticipation of effect of Centers for Medicare
and Medicaid’s Value-Based Purchasing plan
– Reimbursement based in part on satisfaction with
care.
• State of Minnesota, an average of 70% of
patients reported satisfaction with pain
management scores (MDH, 2014)
Staff dissatisfied with current numeric pain
Are Pain Ratings Irrelevant?
• Noted that fellow pain
and palliative care
colleagues didn’t always
ask about pain intensity
using the numeric scale
• In 2015, Short Survey of
Tide of Thought Shifting
• Reliance on
unidimensional
scales to guide
treatment have
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Debate on Self-Report as Gold
Standard in Pediatric Pain IntensityPro:
• Pain is subjective and can only be
assessed via self-report
• Guides appropriate treatments.
Con:
• Reliance on self-reported pain scores
Pain Assessment as a Social
TransactionSchiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676.
• Problem with self-report using a one-dimensional
scale
– Pain is a multi-dimensional complex experience
– Numeric scale difficult for some to use
– Requires linguistic and social skills: problematic
with some of most vulnerable populations
– Patients modulate pain behaviors and self-report
based on their perception of what’s in their best
interest
Patients Modulate Pain Reports Pain Assessment as a Social Transaction
Beyond the “Gold Standard”
• Self-report= gold standard
• Major disconnect between what is advocated and
what clinicians actually do
• “Pain is what the patient says it is” acknowledges
subjectivity of pain, but ignores complex
patient/clinician relationship
• “Pain as 5th Vital Sign” highlights significance of
pain, but can be mechanistic
Pain Assessment as a Social Transaction Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676.
Biological
SocioculturalDevelopmental/Psychological
Experience/EmpathyContextual/Situational
Experience
(Patient Meaning)
Judgment
(Clinician Meaning)
Expression
Assessment
Contributing Factors
Assessment Process Patient Clinician
Pain
StimulusInter-
vention
Examples of Contributing Factors
in Pain AssessmentBiologic Sociocultural Developmental-
Psychological
Experience/
Empathy
Contextual/
Situational
Patient Disease,
clinical
condition,
drug
influences
Ethnicity, sex,
access to
healthcare,
cultural
origin
Age, stress, drug
addiction,
interpersonal
skills, fear
Previous
experience
of pain
Language,
fear/stress,
Similarity to
clinician,
socioeconomic
status
Clinician Biologic
disposition,
stress
reactivity
Pt.
preferences
or biases,
age, sex,
education,
ethnic
background
Views on pain,
trust/suspicion,
Interpersonal
skills, critical
evaluation of
pain report
Knowledge,
clinical
competence,
empathy,
institutional
insensitivity
Workload,
interdisciplinary
communication,
facility resources
Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676
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Summary of the Social Transaction
of Pain Assessment
Pain assessment best described as a dynamic
process, a transaction:
• Intersubjective exchange of meaning between
patient and clinician
• Verbal and nonverbal interaction between
patient and clinician is modified by the
physiologic and social context
• Process dependent on internal/external factors
to both parties and environment
News of a New Tool
University of Utah – 2012 Pilot
Project• CAPA© developed to replace conventional
numeric rating scale (NRS; 0-10 scale)
• Press Ganey© scores increased from 18th to
95th percentile
• 55% patients preferred CAPA ©
Nurses preferred CAPA © 3:1 over NRS
From, Donaldson & Chapman, 2013.
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Clinically Aligned Pain Assessment (CAPA)
“Pain is More Than Just a Number”©
Evaluates
intensity of pain
effect of pain on
functionality
effect of pain on sleep
efficacy of therapy
progress toward comfort
Engages patient and
clinician in a brief From, Donaldson & Chapman, 2013.
CAPA© Tool (modified; original in blue)
The conversation leads to documentation- not the other way around.
Question Response
Comfort •Intolerable
•Tolerable with discomfort
•Comfortably manageable
•Negligible pain
Change in Pain •Getting worse
•About the same
•Getting better
Pain Control •Inadequate pain control Inadequate pain control
•Partially effective Effective, just about right
•Fully effective Would like to reduce medication (why?)
Functioning •Can’t do anything because of pain
•Pain keeps me from doing most of what I need to do
•Can do most things, but pain gets in the way of some
•Can do everything I need to
Sleep •Awake with pain most of night
•Awake with occasional pain
•Normal Sleep
From, Donaldson & Chapman, 2013.
Change or Transformation?
Change is the “fixing” of past to future:
� Better, cheaper, faster, leaner, etc.
Transformation is the job of leaders:
� Building a vision
� Start with the future and
work back
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Transformation
The butterfly is NOT
a better, faster
caterpillar.
It is a NEW
system.
Building an Institutional
Commitment to Pain Management
Gordon DB, Dahl JL, Stevenson KK (1996) and (2000)
• A resource manual that provided a framework to
promote practice changes that would improve
quality of pain management for all patients.
Steps of Implementation
1. Define the scope and team
2. Identify and manage the risks
3. Breakdown the work
4. Schedule the work
5. Communicate
6. Measure progress
From, Verzuh (2008).
University of Minnesota Medical
Center – A River Runs Through It
1932 licensed beds
885 staffed beds
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1. Defining the scope and team –
Phase 1• Scope (Adult Inpatient)
• Medical Units
• Surgical Units
• Behavioral Units
• Obstetrics Units
• Acute Rehabilitation
• Transitional Care
Emergency
• Team
• Champion: Chief
Nursing Executive
• Quality and
Performance
Improvement
Consultants
• Data Analysts
• Electronic Health
Record Consultant
1. Defining the scope and team –
Phase 2
� Infusion Centers
� Clinics
� Procedural Areas
• Scope (Adult Outpatient)
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1. Defining the scope and team – Phase
3
� Process begins with validation of tool in pediatric
population
• Scope (Pediatrics)� Click to edit the outline text
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2. Identify and manage the risks• Potential
failures/risks• Failure to gain
cooperation of
nurses and
physicians
• Concerns of
researchers using
the numeric scale
• Failure to increase
patient satisfaction
• Managing Risks
• Buy-in from key
leaders
• Contacted IRB to
notify researchers of
change
• Weekly monitoring
of process with
monthly monitoring
of outcomes
3 & 4. Breakdown and schedule the work
Aug ‘13 Sept Oct Nov Dec Jan ‘14 Feb Mar April May June July
Take to Leadership groups
Develop content of
presentations
Establish plan for data
collection
Build doc and reports to
support
Form House w ide Group and
unit based group
Engage Stakeholders
Assess current state of
practice, research (
Communicate/educate all
disciplines
Implement: Inpatient
Monitor, evaluate, tweak,
sustain
Month
Determine & Establish
Accountability desired
outcomes, Structure /roles
at all levels
5. Communicate• Who
– Special interest groups: Nurse
Managers/Directors, nursing staff, physician
groups, APRNs, nursing practice committees,
social workers, therapists, champions
• When
– Before, frequently throughout
• What
– Purpose, expected behaviors, expected outcomes,
patient/family feedback, process and outcome
6. Measure progress• Process measures:
– Weekly compliance report per unit
– Identification of individuals still using numeric
scale: can be coached and counseled
• Outcome measures:
– Monthly CAPA© outcomes
– Press Ganey© pain satisfaction scores
Objective 2: Summarize the outcomes of
University of Minnesota Health’s
implementation of CAPA©.
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Electronic Data Abstraction Process Measures
CAPA © Compliance
Outcome Measures - CAPA© Outcome Measures - CAPA©
Outcome Measures – Press Ganey
© • Overall Pain Management
– Staff Did Everything They Could to Help With Pain
– Pain Well Controlled
Press Ganey© - Overall Pain
Management
(by month)
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Press Ganey© - Staff Did Everything to Control
Pain (by Month)Press Ganey© Scores Pre and Post
CAPA Implementation by Quarter
Anecdotes
Patient perspective: “Makes me feel like the
nurses care more about my pain.”
Nurses perspective:
• “It makes sense.”
• Many had been frustrated by numeric scale
and liked the change. “I hated that 0-10
Nurse Survey1 med-surg unit (N=21, 67% return)
80% satisfied or very satisfied with
implementation
80% felt communication with patients improved
with CAPA ©
71% satisfied with rationale for change
66% preferred CAPA© over NRS
Objective 3
• Describe the lessons learned from
implementing a complex and culture-changing
project.
Learnings
• Numeric scale embedded in many different
places in EHR.
• Pain assessment by many different people
– Students, faculty, therapists, technicians, etc.
• Some staff are not skilled at “talking with”
patients; this presented a challenge.
• Some people resist change!
• Staff can be the biggest champions!
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Unexpected Occurrences Information about the CAPA©
tool• Tool not validated according to standards of
psychometrics.
• Study by Drew, Hagstrom & O’Connor-Von
(unpublished) found no correlation between
numerical scores and concurrent CAPA
comfort domain. N=30, repeated measures
Found that can’t compare quantitative data to
qualitative data.
• Donaldson (2014) recommends
nonparametric approach in research design
Additional Learnings
• Staff need to recognize this as culture change
versus a “project”
• Glitches happen in spite of best planning
• Ripple effects of change occur
• Barriers along the way: people, processes,
tools
• Facilitators: people, processes, and tools
Implications for Outpatient
Settings• Pain screening question in clinics = numeric
intensity score gathered by non-professional
– Didn’t cue professional about patient’s pain status
or concerns (documentation not readily visible)
– Didn’t meet the intent of TJC standard to assess
patient’s pain in outpatient setting
Recommendations
for Outpatient Settings• Delete numeric pain scale from intake data.
• Ask screening question: “Do you have pain
that needs to be addressed at this
appointment?”
• Answer flows to Vital Signs flow sheet that is
reviewed by RN and provider
• CAPA available on flow sheet for charting pain
assessment
• Dot phrase available for easy charting in
Recommendations in Process
• “Make it hard to do the wrong thing, and
easy to do the right thing.” Joanne Disch, PhD, RN
• Educate via presentations, electronic
learning, written materials, interpersonal
meetings. Repeat, repeat again….
• Utilize electronic medical record to
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Recommendations
• Speak to fears and concerns:
– Fear of making an “assessment”: some nurses are
more comfortable with patient’s statement of a
number than trying to interpret interaction
– MDs fear that they won’t know how to respond
when nurse calls with CAPA information
• Engage executive leadership as necessary
A Tale of Two Emergency
Departments
West Bank ED 2nd Quarter East Bank ED 2nd Quarter
VP Letter to Staff
Summary
• Pain assessment is not merely the subjective
statement of the patient, no more than it is
the sole objective decision of the clinician.
• Rather, pain assessment is the intersubjective
exchange of meaning between the patient
and clinician.
• It is a process, which is ongoing and
dependent on both the internal and external
factors inherent to both the parties and their
environment.
Summary
• CAPA© is an expanded way to assess pain
using a transactional conversation between
patient and clinician.
• Findings: Changing from the numeric scale to
the CAPA© tool is a cultural change for staff
and patients.
• Next steps at M Health include:
– Expansion to most care settings within hospital
system.
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The Impact
“Nobody makes a
greater mistake than
he who did nothing
because he could do
only a little.”
Edmund Burke
The Power of Many Drops
Questions ? References
Donaldson, G., & Chapman, C.R. (2013). Pain management is
more than just a number. University of Utah Health/Department
of Anesthesiology. Salt Lake City, Utah: Department of
Anesthesiology.
Schiavenato, M., & Craig, K.D. (2010). Pain assessment as a social
transaction: Beyond the gold standard. The Clinical Journal of
Pain, 26(8), 667-676.
University of Utah Health Care. (n.d.). Giving patients a voice, not
a number. Retrieved from:
http://healthcare.utah.edu/nursinginnovation/10ideas/two.php
Verzuh, E. (2008). Fast forward MBA in project management (3rd
ed.). Hoboken, NJ: John Wiley & Sons, Inc.